Acne.
Its about sugar and fats?
Or maybe not?

Thijs R. Klompmaker. wai@waisays.com
Amsterdam
Ortho 2006; 24(4): 176-177

A response to this article:
Van Dongen, J. Acne. Be aware of sugar and fats.
Ortho 2006; 24(3):113-115. (In Dutch)

Dr. Loren Cordain arguments that the western diet is the most probable factor in the etiology of acne, as acne is almost entirely absent in natural living people. Cordain blames consumption of sugar and refined grain products, in combination with a relative lack of omega-3 fats. Analysis of this theory however, reveals some inconsistencies.

Cordain’s theory

Cordain’s theory is based on the fact that hyperinsulinemia, as is the case in polycistic ovary syndrome (POS), is related to hyperandrogenism and acne. Cordain arguments [1] that hyperinsulinemia directly stimulates proliferation of keratinocytes and decreases apoptosis of corneocytes, which indirectly stimulates sebum production as the result of hyperandrogenism, and that the combined effects lead to the sebum canals getting blocked. He speculates that the consumption of high glycemic foods such as sugar, sodas and refined foods has similar effects as hyperinsulinemia, and that the eventual inflammatory effect leading to acne is caused by a lack of omega-3 fats relative to omega-6 fats. As this theory may seem plausible at first glance, we need to evaluate that what it is based upon.

Glycemic index

Cordain assumes that the glycemic index of foods is an indication for the release of insulin after their consumption. This however, is based on two invalid assumptions:

1) That the consumption of high-glycemic food is equal to consuming high-glycemic meals.
2) That a low-glycemic meal evokes less insulin release than a high-glycemic meal.

1) The consumption of high-glycemic foods does not necessarily result in having consumed a high-glycemic meal. You may, for example, drink cola all day without any increasing effect on the release of insulin, as long as all ingested sugars merely replace glucose in the blood that has got lost in the meantime.
2) The glycemic index (GI) represents how fast glucose from consumed carbohydrates ends up in the blood. The effects of proteins and fats are excluded as they are not carbohydrates. Amino acids (the building blocks of protein) however, stimulate the secretion of insulin even more than the same amount of glucose does. [2] Fats also stimulate insulin secretion. [3] Insulin secretion therefore, does not depend on to what extent the consumed meal is high-glycemic, but on the total of all ingested energy, and also on how much energy was already present in the blood before that meal. If there is no marked increase in the levels of glucose, amino acids and fatty acids in the blood, above certain tresholds, there will be no marked increase in insulin secretion either. Since most people don’t consume more than 3 to 5 meals a day, these meals are sufficiently energy dense to evoke a substantial release of insulin on a daily basis.

Hyperinsulinemia and hyperandrogenism

Hyperinsulinemia is related to insulin resistance and often to delayed, and subsequently exaggerated and expanded release of insulin. In healthy subjects the release of insulin is closely related to the influx of energy into the blood, and is the release of insulin and its effects in balance with those of its opponent glucagon. Whereas insulin resistance is hardly reversible, acne generally disappears after puberty, and can therefore not be associated with insulinresistence.. The effects of hyperinsulinemia can therefore not simply be extrapolated to the effects of an increased release of insulin in otherwise healthy acnepatients.

Omega-3 fatty acids

Without inflammation there is no acne. If the inflammatory effect would be caused by a relative lack of omega-3 fatty acids, omega-3 fatty acids supplementation should therefore be an effective remedy against acne. Since the existence of acneforums on the internet acnepatients have been experimenting with supplements in their effort to fight acne. ‘Healthy’ non-description anti-acne medication would be very much welcomed by every acnepatient. If someone posts having success with a specific supplement, many step into his footsteps instantly. That was how ‘the vitamin B5 craze’ originated. Megadose intake of this vitamin appeared to have pharmaceutical effects, reducing the secretion of sebum and therefore diminishing acne. Some of the reported side effects are headaches, dry skin, dizzyness and nausea. Inevitably, many have experimented with omega-3 fatty acid supplementation as well. Unfortunately without inspiring results.

Diet after all?

85% of adolescents had acne at some point [4] and 89% of female acnepatients had acne since the onset of menarche. [5] Hormones therefore seem to play a major role. Since in ‘only’ 61% of female acnepatients the level of one or more androgens is somewhat elevated [6], there however needs to be another causative factor. Cordain’s observation that acne seems to be absent in naturally living people might be valid, but the underlying reason may be different. It may be because of the lack of added salt or the substantial lower intake of (cooked) protein for example, as it is known that both salt and protein are hydrophylic compounds, and that facial edema is very much related to acne. [7] Acne may therefore be the result of pinched off sebumcanals in combination with a relatively high production of sebum. As protein decomposing enzymes are absent in the skin [8], the former may be caused by local swelling of the skin, and the latter may be caused by genetic predisposition and/or hormonal influences. Maybe protein, salt and hot spices are more credible suspects when trying to find out how our Western diet may make us susceptible to acne [9].

SOURCES

[1] Cordain L. Implications for the role of diet in acne. Semin Cutan Med Surg 2005; 24(2):84-91. Complete article in PDF format
[2] J C Floyd, Jr, S S Fajans, J W Conn, R F Knopf, and J Rull, Stimulation of insulin secretion by amino acids. J Clin Invest. 1966 September; 45(9): 1487–1502.
[3] Xiao C, Giacca A, Carpentier A, Lewis GF., Differential effects of monounsaturated, polyunsaturated and saturated fat ingestion on glucose-stimulated insulin secretion, sensitivity and clearance in overweight and obese, non-diabetic humans. Diabetologia. 2006 Jun;49(6):1371-9.
[4] Rabinowitz, L.G. ,Acne Vulgaris. Adolesc. Med. 1997 / 8 (1) / 77-86.
[5] Cibula, D. et al, Prediction of increased levels of androgen in women with acne vulgaris using ultrasound and clinical parameters. (in Czech) Ceska. Gynekol. 1999 / 64 (4) / 242-246.
[6] Thiboutot, D. et al, Androgen metabolism in sebaceous glands from subjects with and without acne. Arch. Dermatol. 1999 / 135 (9) / 1041-1045. , Cibula, D. et al, Prediction of increased levels of androgen in women with acne vulgaris using ultrasound and clinical parameters. (in Czech) Ceska.Gynekol. 1999 / 64 (4) / 242-246.
[7] Dragan, L.R. et al, Solid facial edema preceding a diagnosis of retro-orbital B-cell lymphoma. J. Am. Acad. Dermatol. 2000 / 42 (5 Pt 2) / 872-874. , Mendez-Fernandez, M.A. ,Surgical treatment of solid facial edema ; when everything fails. Ann. Plast. Surg. 1997 / 39 (6) / 620-623.
[8] Dutta, A.S., Small Peptides, Chemistry, Biology and Clinical Studies, Elsevier Science Amsterdam 1993 / 593.
[9] www.freeacnebook.com